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4APPLICATION FOR INELL►PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIA ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, %X EAST WEBER AVENUE,STOCKTON. CA 95201388 (209) 499-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 19 NEW BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTICONSTRUCT INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WNR SETH JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY RUBUC HEALTII BERICEB,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSATR APN/ ►i a 9 S QI I, S aC r .m p ln+n S_ g•,. ,�,B Log;p I F% 1 CO CITI nrL//�Y PARCEL SIZEIAM, "es'?16,040 OWNER'S NAME RtAA Nclg. RIAO XCOmPan ADDRESSIRHONE CONTRACTOfl 01 P1fRIQ '(NJ1229xs''fShcfameK ADDRESS PHON $9 BUB CONTRACTOR_Q II 1 rfglrl (�kPl[]Y'a�-ion brit SIR I�(y� �1 O� AOOgEee P Qqu,n-I'6t�v,�/�, UCT/ RHONE/�j10 7 jl_.E 9,'7 TYPE OF WE JPUMI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ 0 OTHER 1+ ❑ INSTALLATION 13 WELL SYSTEM REPAIR ❑ CR088CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑Naw❑Racal, H.P. J (TYPE OF PIUMPI DEPTH RUMP SET--FT. FIR"WATER LEVEL El DESTDESTRUCTION! UT �_ ❑ O -0FRVN: BEE WELL ❑ OEOP1HYSMAL WELL/ to BOIL BORING 1100 f (� B INTENDED USE TYPE OF WELL Imagism i c CONSTRUCTION SPECIRICA710N6 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A ❑ OOMESTIC/ROVATE ❑GRAVEL PACK/SIZEDIA.OF CONDUCTOR CASINO D TYPE OF ROU/eT L/PVC DIA.OF WELL CASING ❑ PUBUC/MVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O ❑ IRRIOATIONIAG ❑OTHER SPECIFICATION R Yy GROUT SEAL INSTALLED BY BMW BRAND NAME MONITORING ED: Ely. ❑Ne E AP^RIG%.DEPTH_ GROUT SEAL PUMP / S �T CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S LOCKING CHEETEp BO%/STOVE RPE PROPOSED CON/TRUCTONIDMLUNG METHOD: MUD ROTARYS AIR ROTARY AVGER _CABLE OTHER 1 REGULATIONS CERTIFY THAT I JOA RIEPAR U TMS HOME OWNER AND THAT TNA WOIK WILL BE PONE HN ACCORDANCE WITH BAN JOI COUNTY ORDINANCES,STATE UWB,AND RULES AND REODUTONB OF THE BAN JOAQUIN COVNTV, HOME OW?HEp OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMR IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S/RRINO OR BUBCONTMCTINO SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TOW-CONT 'I COMPFNMTIDN LAWS OF CALIFORNIA.- THE�//PPIICANT MWT CALL ZI OMS IM ADVANCE FOR ALL REQUIRED INIP[CTONI AT IZSII ApJtA31. COMPLETE DRAWING AT LOWER AREA N'S COM elSned X_'K rW 1 1 .Y 1 1 p Tltls_SY �t'QILC� .SCI M1 l�.S� Data q PLOT PUN ID.aw to%,.I Beal. •Ia 1. NAMES OF STREETS OR MADS NEAREST i0 OR SOON PLOT THE PROPERTY. Z. OVTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR ROTOBED 3. DIMENSIONED OUTLINES ANO LOCATON OF ALL EXISTING AND P10PO8AD EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AM WAIXB. S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. PAYMlEty SEP 16. 1996 . /C E'kiTH SERVIC ENVIRON ES .. E 1TAL HEALTH D.VISIp� DERMTMENT USE ONLY APPlleepen Awwte l BY bet. Nu Orem Incaution BY Date RvnP I..Pwtl.n By DwVmtbn luewtlen By Data Dale Cemmerna: ACCOUNTING ONLY: AID/ FACS PE CODES FEE INFO AMOUNT REMITTED C /CASH RECEIVED BY DATE PEINIITIIEIMCE REQUEST NUMBER S INVOICE J S � Pub.Health Sew.-Emil 173(3/96)